What Happened

A nurse in Clear Lake, Iowa diverted liquid fentanyl meant for elderly patients by drawing it directly out of their IV pumps with a syringe.

He diverted liquid fentanyl that was supposed to be dispensed to patients under his care, removing it from the patients' IV pumps with a syringe for his own personal use. The diversion was uncovered through an investigation by the Iowa Department of Inspections and Appeals Investigations Division, Medicaid Fraud Control Unit.

He pleaded guilty on November 21, 2022, in federal court in Sioux City, Iowa, to acquiring a controlled substance by misrepresentation, fraud, deception, and subterfuge. He remained free on bond pending sentencing, facing a possible maximum sentence of four years' imprisonment, a $250,000 fine, and one year of supervised release.

What Went Wrong

A nurse was able to withdraw fentanyl directly from elderly patients' IV pumps for personal use before the diversion was detected. Key failures included:

  • Fentanyl delivered through patient IV pumps was not reconciled against programmed and actual infusion volumes to catch withdrawals made after the pump was set up.
  • Elderly patients receiving continuous or PRN opioid infusions were not monitored for under-treated pain that could signal a missing dose.
  • No routine tamper check on in-use IV lines and pump reservoirs flagged access points where a syringe could be used to withdraw drug.

How It Could Have Been Prevented

  • Reconcile programmed infusion pump volumes against actual remaining fentanyl volume at shift change and before pump changeovers.
  • Monitor elderly and vulnerable patients on opioid infusions for unexplained breakthrough pain that may indicate a diverted dose.
  • Use tamper-evident IV pump reservoirs and access ports that make direct syringe withdrawal detectable.
  • Require two-person verification when accessing or adjusting in-use patient-controlled or continuous opioid infusions.

Related Guidance

Sources